Rep. Blackburn Introduces Prior Authorization Bill

Tenn. lawmaker’s legislation would require CMS program to establish a program for higher cost DME similar to the power mobility demonstration project.

Rep. Marsha Blackburn (R-Tenn.) has introduced H.R. 2437, new legislation that would see a prior authorization program established for certain high-cost DME and supplies.

The bill, which was referred to the Committee on Energy and Commerce as well as the Committee on Ways and Means, would require CMS to devise a prior authorization program for higher ticket DME items that would exempt approved claims for those items from subsequent audits.

The nascent legsilation would require that the program ensure timely beneficiary access to care; implement standard medical necessity evaluation; and create an expedited review process to facilitate same-day delivery of critical items such as oxygen. Additionally, one key requirement is that stakeholders help develop the prior authorization process.

The program would be similar to the power mobility device (PMD) prior authorization demonstration that has been in process in seven states since September 2012, but would cover a broader range of DME items beyond PMDs. CMS expanded the program to 12 additional states in October 2014. The demo ends Aug. 31 for all states with the original demonstration requirements remain the same for all 19 states.

Generally speaking, the prior-authorization project has been received favorably by participating PMD providers, because up-front approval on claims minimized future audit concerns. In fact, the new Blackburn legislation would require the new program to specifically target high-price DME items that receive a high number of audits.

“Several DMEPOS suppliers have suggested prior authorization helps their business by providing a more predictable cash flow and improved relationships with the ordering physician,” CMS noted in a December 2014 update on the PMD prior authorization demonstration. “These DMEPOS suppliers have expressed support for the demonstration and would like it to be expanded to other states and items.”

About the Author

David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on Twitter at @postacutenews.

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